Size matters in atrial fibrillation: the underestimated importance of reduction of contiguous electrical mass underlying the effectiveness of catheter ablation

Abstract Evidence has accumulated over the last century of the importance of a critical electrical mass in sustaining atrial fibrillation (AF). AF ablation certainly reduces electrically contiguous atrial mass, but this is not widely accepted to be an important part of its mechanism of action. In th...

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Bibliographic Details
Published in:Europace (London, England) England), 2021-11, Vol.23 (11), p.1698-1707
Main Authors: Hartley, Adam, Shalhoub, Joseph, Ng, Fu Siong, Krahn, Andrew D, Laksman, Zachary, Andrade, Jason G, Deyell, Marc W, Kanagaratnam, Prapa, Sikkel, Markus B
Format: Article
Language:English
Subjects:
Animals
Atrial Fibrillation - diagnosis
Atrial Fibrillation - surgery
Catheter Ablation - adverse effects
Catheter Ablation - methods
Heart Atria - surgery
Humans
Mammals
Mice
Review
Treatment Outcome
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Summary:Abstract Evidence has accumulated over the last century of the importance of a critical electrical mass in sustaining atrial fibrillation (AF). AF ablation certainly reduces electrically contiguous atrial mass, but this is not widely accepted to be an important part of its mechanism of action. In this article, we review data showing that atrial size is correlated in many settings with AF propensity. Larger mammals are more likely to exhibit AF. This is seen both in the natural world and in animal models, where it is much easier to create a goat model than a mouse model of AF, for example. This also extends to humans—athletes, taller people, and obese individuals all have large atria and are more likely to exhibit AF. Within an individual, risk factors such as hypertension, valvular disease and ischaemia can enlarge the atrium and increase the risk of AF. With respect to AF ablation, we explore how variations in ablation strategy and the relative effectiveness of these strategies may suggest that a reduction in electrical atrial mass is an important mechanism of action. We counter this with examples in which there is no doubt that mass reduction is less important than competing theories such as ganglionated plexus ablation. We conclude that, when considering future strategies for the ablative therapy of AF, it is important not to discount the possibility that contiguous electrical mass reduction is the most important mechanism despite the disappointing consequence being that enhancing success rates in AF ablation may involve greater tissue destruction.
ISSN:1099-5129
1532-2092
DOI:10.1093/europace/euab078